Mantua Township Fire District No. 1
Firefighter Application
7/08

Dear Applicant,

We welcome your membership application to join the Mantua Township Fire Department. This application packet contains all of the requirements, forms and instructions to complete the process. It is important that you complete the application completely and honestly.

Specifically, this packet contains the following sections:
1. Application Instructions
2. Physical Information – Contact Phone Number
3. Disqualifier – Eligibility Criteria
4. Fingerprinting Information
5. Personal Data
6. Residency Information – References
7. Education – Employment
8. General – Criminal History
9. Motor Vehicle History

I am sure that you will agree that our organization is one in which integrity is paramount and our reputation is directly related to the conduct that is displayed by each of our members. Each one of our members interacts with the public and has responsibility for the welfare and general safety of the same; therefore, we do scrutinize the information that you place on the application.

We encourage you to visit our fire stations, talk to our members, officers and Board of Fire Commissioners’ and examine our Policies, Procedures and Standard Operating Guidelines Manual for more information.

Thank you for your interest and hopefully you will become a valuable part of the Mantua Township Fire Department.

Sincerely,

Section 1: Application Instructions

The applicant shall personally prepare this form and all signatures must be in black ink. Read and answer each question carefully. Answer every question and do not leave blank spaces. Write either ‘Not Applicable’ or ‘N/A’ in lieu of leaving a blank space. An applicant may be rejected for providing false information.

If there is not enough space to answer a question then you may use another sheet of paper and reference the question number.

All applications must be accompanied by a copy (not originals) of your Birth Certificate, Drivers License, Social Security Card, Military Service Record DD214 Form, High School Diploma or equivalent and college transcripts (as applicable).

Section 2: Ineligibility Criteria

No applicant for the position of Firefighter with the Mantua Township Fire District No. 1 shall be considered for membership/employment and shall be removed from the eligibility list, if during the membership/employment process it is discovered that the applicant:

Driving Record

• Have one (1) or more DWI convictions.
• Have one (1) or more DUI convictions.
• Have a combination of one (1) DWI and DUI convictions.
• Have ten (10) or more moving violations.
• Have six (6) or more current points.
• Have two (2) or more non-payment of insurance surcharges.
• Have two (2) or more non-payment of Parking Ticket Adjudication Act.
• Have a combination of two (2) or more non-payment of insurance surcharge and/or Parking Ticket Adjudication Act.
• Have two (2) or more convictions for driving when suspended.
• Has failed to appear in court two (2) or more times.
• Have two (2) or more convictions for reckless driving.
• Does not possess a valid New Jersey Driver’s license.

Criminal History

• Has been arrested and convicted of any offense which involves dishonesty (including offenses under 2C:51-2).
• Has been arrested and convicted of any offense which touches on the position of Firefighter.
• Has been arrested and convicted of any offense which is a third degree or higher (including offenses under 2C:51-2).
• Has been incarcerated for a conviction in a correctional facility of any jurisdiction.
• Is pending Grand Jury action or trial for any offense in any jurisdiction.
• Is presently on probation as part of a Conditional Discharge or Pre-Trial Intervention Program.
• Has been convicted of any Domestic Violence offense (“lautengurg Amendments).
• Has been convicted for any offense under N.J.S.A. 2C:35 or Title 24 (including disorderly persons or petty disorderly persons offenses, including these under 2C:51-5).
• Has entered into a Conditional Discharge agreement or Pre-Trial Intervention program for any offense under 2C:35 or Title 24 (including disorderly persons of petty disorderly offenses).

Other

• Is not a resident of the State of New Jersey.
• Refuses to consent to any part of the security and/or background investigation.
• Has had their employment from a Federal, State, County or Municipal Fire Department terminated for disciplinary reasons or has resigned “not in good standing” from these types of positions.
• Has been found to falsify any document or intentionally given false information in any part of this employment process.
• Has failed to meet any one of the requirements of the employment screening process.
• Has refused/failed to submit a urine sample or has submitted a urine sample which has been found to be positive for any unauthorized controlled substance.
• Has an unacceptable past employment history (disciplinary action for performance and/or attendance).

Section 3: Release Authorization

To all Courts, Probation Departments, Physicians, Hospitals, Employers, Educational and other Institutions and Agencies without exception.

I, __________________________ am making application to the Mantua Township Fire District No. 1 and, as a result, an investigation is being conducted to determine my eligibility for membership/employment.

Therefore, you are authorized to release to the Mantua Township Fire District No. 1, or its representatives, all information, documents or records that may be requested.

I hereby release, discharge and exonerate and hold harmless the Mantua Township Fire District No. 1, its agents or representatives and any person so furnishing information, from any liability of every nature and kind arising out of the furnishing, inspecting or collection of such documents, records and other information or the investigation made by the Mantua Township Fire District No. 1.

A photo static copy of this authorization will be considered as effective and as valid as the original.

Signature: __________________________________ Date: ____________

Witness Name (Print): _________________________ 

Witness Signature: ___________________________ Date:_____________

Section 4: Fingerprinting Information

Name: ___________________________________

Date of Birth: ______/______/______

Sex: __________ Race: __________ Height: __________

Weight: _______ Hair Color: _______ Eye Color: _______

Place of Birth: _____________________________

Citizenship: __________ Social Security #: _____-_____-_____

Current Address: _________________________________________________
Street City State Zip

Telephone Number(s): ____________________________________

Employer & Address: _____________________________________

_____________________________________

Occupation: ____________________________________________

Scars, Marks, Tattoos, Amputations: _________________________

Alias: __________________________________________________

Name & address of nearest relative & relationship: ______________

Driver’s License No.: ______________________ State: __________

Section 4: Personal Data

1. What is your full name ____________________________________________
(Last) (First) (Middle)

2. Give any other names you have used or have been know by and attach a statement giving reasons.
A. ___________________________ C. ___________________________

B. ___________________________ D. ___________________________

3. Date of birth: ____________________ Age at time of application: _________
(Month) (Day) (Year)
Sex: ___ Height: _____ Weight: _____ Eye Color: _______ Hair Color: ______
4. Where were you born? ____________________________________________
(Hospital) (City) (State)

5. Birth Certificate: _________________________________________________
(City) (County) (State)

6. Social Security Number: _______-_______-_______ State of issue: ________

Section 5: Residence

1. Where do you currently reside? _____________________________________
(Number) (Street) (City) 

_____________________________________
(County) (State) (Zip Code) 

2. How long have you lived at the above address? ________________________

3. In chronological order, list each and every place that you have lived during the past ten (10) years, beginning with your present address:

Starting Ending
Month Year Month Year Complete Address

Section 6: References

Provide four references (not relatives) who have known you well during the past five (5) years, excluding Firefighters from the Mantua Township Fire District #1.

1. Name: ______________________________ 
Address: ____________________________ Phone #: ________________

2. Name: ______________________________ 
Address: ____________________________ Phone #: ________________

3. Name: ______________________________ 
Address: ____________________________ Phone #: ________________

4. Name: ______________________________ 
Address: ____________________________ Phone #: ________________

Section 7: Education
List chronologically (earliest first) all schools and colleges you have attended:

School Address # Years Degree Type Graduated Y or N

Section 8: Employment
Present Employer: _____________________________________________ 

Address: _______________________________________________________ 

Supervisors Name: ________________________Phone: _________________

Describe Job Duties: _____________________________________________

Have you ever been discharged or asked to resign from employment: Y or N

If Yes, please explain: _____________________________________________

_______________________________________________________________ 

Section 9: Motor Vehicle History
Have you ever had your Motor Vehicle License revoked or suspended in this state or any other state: Y or N 

If Yes, please explain: ______________________________________________

Have you ever had your Motor Vehicle Registration revoked or suspended in this state or any other state: Y or N

If Yes, please explain: ______________________________________________

List any motor vehicle summonses or violations for the past three years in this state or any other state:
Date Offense Location Court Disposition Points Police Agency

I, ________________________________ being duly sworn, depose and say I am the named person. I signed the forgoing statement, I personally read and printed by hand, answers to each and every question therein and I do solemnly swear that each and every answer is full, true and correct in every respect.

“Under Penalty of Law”, a person who makes a false statement under oath or equivalent affirmation, or swears or affirms the truth of such a statement previously made, when he does not believe the statement to be true, is guilty of a crime of the fourth degree in violation of NJAC 2C:28-2.

______________________________
(applicant sign here)